Ask a Policy Wonk: "How Can I Get Ready for Health Care Reform?"

Thanks to the Affordable Care Act, millions of uninsured or under-insured Americans -- including those whose HIV rendered them "uninsurable" -- will soon be able to purchase health insurance or become eligible for new federally funded Medicaid programs to cover their health care costs. Coverage begins January 1, 2014, but open enrollment in both the newly expanded Medicaid programs and the state-by-state insurance "marketplaces" begins October 1, 2013 -- just two short weeks away.

What can you do to prepare for open enrollment and get the most from health care reform?

Courtney Mulhern-Pearson, M.P.H.

Courtney Mulhern-Pearson, M.P.H., director of state and local affairs at San Francisco AIDS Foundation and a member of the San Francisco HIV Health Care Reform Task Force, explains how HIV-positive individuals (here in California and beyond) and their medical providers can get ready for the changes ahead.

First of all, is it important to enroll right away, as soon as open enrollment begins on October 1? And what can people be doing to get ready to enroll?

Courtney Mulhern-Pearson: No, it's absolutely not necessary to enroll right away. In fact, there are good reasons why people may want to take their time.

The open-enrollment period is October 1, 2013, through March 31, 2014; however, you must be enrolled by December 23 if you want your plan to be in effect by January 1, 2014. That said, I would advise people not to rush and sign up on October 1. Not every state will have released complete information about their plans before October 1, and you really want to do your research and make sure you sign up for the right plan. If possible, take the month of October to study and understand the plan offerings and costs, and then maybe set a goal of signing up sometime in November so you can easily make the cut-off.

Also, people who have been relying on Ryan White programs and AIDS Drug Assistance Programs [ADAPs] for their care and medications will need to understand how their coverage may change. Many states are expanding their Medicaid programs so that people at higher incomes -- 138% of the federal poverty level -- will become eligible. Because Ryan White is a "payer of last resort," as more people become eligible for Medicaid, Ryan White may no longer be able to pay for their care and treatment. Here in California, for example, it's estimated that 55% of people who are currently relying on Ryan White programs will become eligible for Medi-Cal [PDF], California's Medicaid program.

It's not yet clear how these programs will interact with health insurance plans in some states -- another reason not to hurry and sign up for an insurance plan before you can review and understand all your options for paying for your medical care. Try to find a benefits counselor or other trained "navigator" who understands the changes coming with health care reform and who can talk you through your eligibility for different programs. And for providers, it's important to use this time to sort out which of your current clients will be eligible for which programs.

What do you see as the most important things for people to think about as they weigh their new health care options?

Mulhern-Pearson: Affordability, provider network, and formulary. Those are some of the key things for people to consider as they assess the plans available to them.

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It's essential to really understand what you're signing up for and make sure you can afford to use your benefit. My fear is that people will sign up for a plan that is just unaffordable for them. Once the information for your state's plans is released, you and your benefits counselor or navigator can use the Marketplace Health Plans Assessment Worksheet to compare your options and identify one that is the right fit for you, given your income and the financial assistance programs available to you. The worksheet is very detailed: You can fill in and compare the costs associated with multiple different plans, as well as whether they work with ADAPs and other state assistance programs.

Focusing on California, you can go to CoveredCA.com now to see what plans are going to cost and think about your options. If your income is at or below 400% of the federal poverty level [FPL], you will qualify for federal tax credits. These are applied to insurance premiums, which reduces the amount you owe each month for your health insurance. Additionally, if your income is less than 250% of the federal poverty level, you should also qualify for cost-sharing subsidies that will reduce the amount of money you have to pay for health care expenses such as co-payments or co-insurance.

For people with HIV, there are a few additional programs to help make new coverage more affordable. If your income is at or below 400% of the federal poverty level, you should make sure you are enrolled in ADAP to cover medication co-pays. There's also a California program called OA-HIPP, the Office of AIDS Health Insurance Premium Payment program. It has the same eligibility level as ADAP, and it can be used to pay your insurance premiums. So if your income is at or below 400% of FPL, you may be eligible for coverage of premiums through OAHIPP and medication co-pays through ADAP. You'll still have to cover your medical visit co-pays yourself.

So here's where it gets really complicated (and why it is a good idea to seek out a benefits counselor to help you select the right combination for you): If your income is between 138% and 200% of the federal poverty level, the combination of the federal tax credits, cost-sharing subsidies, ADAP, and OA-HIPP will probably make one of the "silver" plans offered in your area the most cost-effective choice for you. However, if your income is over 200% FPL, it might make more sense for you to pick a higher-level plan, like a "platinum" plan. The premiums in those plans are higher, but the out-of-pocket costs are lower. If you qualify to get the premiums covered by OA-HIPP, picking the more expensive plan might be the best way to keep your out-of-pocket costs lower.

In addition to helping you compare plan costs, the assessment worksheet can help you identify your needs and priorities. What is most important to you: Getting care with the absolute lowest out-of-pocket costs? Making sure something beyond general health and HIV care -- such as mental health care or substance use treatment -- is also covered affordably and by a provider you trust? Staying with the medical provider you have now?

If staying with your current provider is important to you, even if your state hasn't yet released its plan information, you can call your provider's office now and ask which plans she or he is contracted with. Then when open enrollment starts, make sure you sign up with a plan that your doctor is contracted with, to ensure that continuity.

It's still unclear how adequate the HIV provider network is going to be within the various plans. If you want or need to switch providers, do some research into the providers contracted with the various plan networks; you'll want to know what their experience is with treating HIV, and whether they are accepting new patients.

Another extremely important thing to consider when you're picking a plan is the formulary -- that is, what medications the plan covers. Most plans should cover HIV medications, but you really want to make sure your all meds are on there -- and at the dosing levels you use, if possible.

If your medications or your dosing levels aren't covered, it doesn't mean you can't get them, but it may require more paperwork. Your provider may need to get prior authorization from the insurance company every month before you can refill your prescriptions, or you might be required to substitute another "biosimilar" drug instead. For example, in San Francisco, when the Medicare managed care roll-out happened, one drug was not covered at the dosing that people needed. Advocates were able to work with the plan manager to get the formulary adjusted.

I think there will be some room for potential improvement as health care plans get adjusted to treating the HIV-positive population. I don't know if that will be true of all plans everywhere, but it's at least worth exploring.

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